Ultrasound guided costoclavicular block in pediatric population: A prospective observational study.

BACKGROUND: The costoclavicular space serves as an alternative approach to the infraclavicular brachial plexus block, and numerous studies in adults have demonstrated promising outcomes for distal upper limb surgery. Blocking the brachial plexus at this level is potentially advantageous because the cords are relatively superficial, located in close proximity to each other and easily identified using ultrasound. AIMS: This study aimed to assess the success rate and feasibility of costoclavicular block in children undergoing unilateral below elbow upper limb surgery. METHODS: Thirty children aged 2-12 years scheduled for unilateral below elbow surgery under general anesthesia were included. Costoclavicular block was performed under ultrasound and nerve stimulator guidance with 0.5% ropivacaine, 0.5 mL/kg. Success was evaluated based on the absence of significant hemodynamic response to skin incision made 20 min after the block. The sono-anatomy of costoclavicular space, ease of needling, complications, and the post-operative pain scores were assessed. RESULTS: The mean age and weight of the children were 6.5 ± 3.8 years and 19.7 ± 9.1 kg, respectively. The success rate of costoclavicular block in our cohort is 100%. Sonographic visualization was graded as excellent (Likert Scale 2) in 90% of cases. The plexus was located at a depth of 1.4 ± 0.3 cm from the skin, the lateral extent of cords from the artery was 0.8 ± 0.4 cm and they were observed inferior and lateral to the artery. The mean needling time was 3.6 ± 1.1 min. None of the children experienced complications such as vascular or pleural puncture, hematoma, Horner's syndrome or diaphragmatic palsy. Postoperative pain scores were low, and no rescue analgesia was required. CONCLUSIONS: In conclusion, the costoclavicular block exhibited a notably high success rate in pediatric population. This study substantiates that the three cords of the brachial plexus are consistently visible and superficial during ultrasound examination using this approach, confirming their separation from vascular structures and the reliable achievement of blockade without observed complications.

Efficacy and safety of ketamine as an adjuvant to regional anesthesia: A systematic review and meta-analysis of randomized controlled trials.

STUDY OBJECTIVE: To identify whether adding ketamine to the local anesthetics (LA) in the regional anesthesia could prolong the duration of analgesia. DESIGN: A Systematic review and meta-analysis of randomized controlled trials. SETTING: The major dates were obtained in the operating room and the postoperative recovery ward. PATIENTS: A total of 1011 patients at ASA physical status I and II were included in the analysis. Procedure performed including cesarean section, orthopedic, radical mastectomy, urological or lower abdominal surgery and intracavitary brachytherapy implants insertion. INTERVENTIONS: After an extensive search of the electronic database, patients received regional anesthesia combined or not combined general anesthesia and with or without adding ketamine to LA were included in the analysis. The regional anesthesia includes spinal anesthesia, brachial plexus block, pectoral nerve block, transversus abdominis plane block and femoral and sciatic nerve block. MEASUREMENT: The primary outcome was the duration of analgesia. Secondary outcomes were the duration and onset time of motor and sensory block as well as the ketamine-related adverse effect. Data are expressed in mean differences in continuous data and odds ratios (OR) for dichotomous data with 95% confidence intervals. The risk of bias of the included studies was evaluated using the revised Cochrane risk of bias tool for randomized trials. The quality of evidence for each outcome was rated according to the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) Working Group system. MAIN RESULT: Twenty randomized controlled trials were included in the analysis. When ketamine was used as an adjuvant to LA, the duration of analgesia could be prolonged(172.21 min, 95% CI, 118.20 to 226.22; P<0.00001, I2 = 98%), especially in the peripheral nerve block(366.96 min, 95% CI, 154.19 to 579.74; P = 0.0007, I2 = 98%). Secondary outcomes showed ketamine could prolong the duration of sensory block(29.12 min, 95% CI, 10.22 to 48.01; P = 0.003, I2 = 96%) but no effect on the motor block(6.94 min, 95% CI,-2.65 to 16.53;P = 0.16, I2 = 84%), the onset time of motor and sensory block (motor onset time, -1.17 min, 95% CI, -2.67 to 0.34; P = 0.13, I2 = 100%; sensory onset time, -0.33 min, 95% CI,-0.87 to 0.20; P = 0.23, I2 = 96%) as well as the ketamine-related adverse effect(OR, 1.97, 95% CI,0.93 to 4.17;P = 0.08, I2 = 57%). CONCLUSION: This study indicates that ketamine could be an ideal adjuvant to local anesthetics regardless of the types of anesthesia. Overall, the quality of the evidence is low.

Continuous Interscalene Brachial Plexus Blocks: An Anatomical Challenge between Scylla and Charybdis?

Brachial plexus blocks at the interscalene level are frequently chosen by physicians and recommended by textbooks for providing regional anesthesia and analgesia to patients scheduled for shoulder surgery. Published data concerning interscalene single-injection or continuous brachial plexus blocks report good analgesic effects. The principle of interscalene catheters is to extend analgesia beyond the duration of the local anesthetic's effect through continuous infusion, as opposed to a single injection. However, in addition to the recognized beneficial effects of interscalene blocks, whether administered as a single injection or through a catheter, there have been reports of consequences ranging from minor side effects to severe, life-threatening complications. Both can be simply explained by direct mispuncture, as well as undesired local anesthetic spread or misplaced catheters. In particular, catheters pose a high risk when advanced or placed uncontrollably, a fact confirmed by reports of fatal outcomes. Secondary catheter dislocations explain side effects or loss of effectiveness that may occur hours or days after the initial correct function has been observed. From an anatomical and physiological perspective, this appears logical: the catheter tip must be placed near the plexus in an anatomically tight and confined space. Thus, the catheter's position may be altered with the movement of the neck or shoulder, e.g., during physiotherapy. The safe use of interscalene catheters is therefore a balance between high analgesia quality and the control of side effects and complications, much like the passage between Scylla and Charybdis. We are convinced that the anatomical basis crucial for the brachial plexus block procedure at the interscalene level is not sufficiently depicted in the common regional anesthesia literature or textbooks. We would like to provide a comprehensive anatomical survey of the lateral neck, with special attention paid to the safe placement of interscalene catheters.

The effect of block side on hemodynamic and respiratory parameters in patients who had interscalene block for upper limb surgery.

OBJECTIVE: The administration of interscalene block (ISB) may lead to several hemodynamic effects, likely due to the diffusion of local anesthetic to nearby structures such as carotid sinus baroreceptors. This study aimed to compare hemodynamic and respiratory changes resulting from right and left-sided ISB. PATIENTS AND METHODS: A retrospective analysis was conducted on adults who had ultrasound-guided ISB for upper limb surgery between January 2020 and December 2021. All patients had ISB with bupivacaine 0.5% and lidocaine 2% mixture following premedication. Demographic data, arterial blood pressure, heart rate, and peripheral oxygen saturation (SpO2) were measured before and after the block at regular intervals. Block characteristics, surgical and post-anesthesia care unit (PACU) durations, intraoperative analgesic requirements, and side effects were analyzed. RESULTS: A total of 94 patients had ISB for upper limb surgery, 54 for the right and 40 for the left-sided surgeries. Patients' data were analyzed in two groups according to the block side. Increased arterial blood pressure was observed in both groups after the block compared to the control values. Systolic arterial pressure from 10 to 30 minutes, diastolic arterial pressure at the 25th minute, and mean arterial pressure at the 15th, 20th, and 25th minutes were significantly higher on the right-sided blocks. Heart rate, SpO2, analgesic requirements, block characteristics, and PACU durations did not differ between the groups. CONCLUSIONS: Ultrasound-guided ISB-applied patients demonstrated increased blood pressure compared to control values. This increase, without concurrent changes in heart rate, was more pronounced in right-sided ISB. These findings indicate that careful hemodynamic monitoring is necessary whenever hypertension should be avoided for the patients.

Comparison of the incidence of inadvertent perioperative hypothermia between general anesthesia and interscalene brachial plexus block in shoulder arthroscopy: A randomized prospective study.

INTRODUCTION: Inadvertent perioperative hypothermia (IPH), defined as core body temperature below 36°C, is associated with various complications. Shoulder arthroscopy is a risk factor of IPH. This study aimed to compare the incidence of IPH between general anesthesia (GA) and interscalene brachial plexus block (ISBPB) for shoulder arthroscopy. METHOD: Patients scheduled for shoulder arthroscopy were prospectively enrolled and randomly assigned to GA or ISBPB groups. The body temperature of the patients was measured from baseline to the end of anesthesia and in the post-anesthetic care unit to compare the incidence of IPH. RESULTS: Of the 114 patients initially identified, 80 were included in the study (GA = 40, ISBPB = 40). The incidence of IPH differed significantly between the groups, with GA at 52.5% and ISBPB at 30.0% (P = .04). Profound IPH (defined as < 35.0°C) occurred in 2 patients with GA. Upon arrival at the post-anesthesia care unit, the GA group exhibited a significantly lower mean body temperature (35.9 ±â€…0.6°C) than the ISBPB group (36.1 ±â€…0.2°C, P = .04). CONCLUSION: The incidence of IPH in the GA group was higher than that in the ISBPB group during shoulder arthroscopy, suggesting that ISBPB may be a preferable anesthetic technique for reducing risk of IPH in such procedures.

Comparison of ultrasonography-guided lateral versus medial costoclavicular brachial plexus block in pediatric patients : A randomized clinical trial.

BACKGROUND AND AIMS: Costoclavicular brachial plexus block is gaining popularity due to its ease of application. Lateral and medial costoclavicular approaches have recently been defined. In the current study, we aimed to investigate the procedural execution of these approaches in the pediatric population. METHODS: In this study 55 children aged between 2 and 10 years were randomized to receive lateral (LC group) or medial (MC group) costoclavicular brachial plexus block after induction of general anesthesia for postoperative analgesia. All patients received bupivacaine (1 mg/kg, 0.25%) within the center of the cord cluster. The number of needle maneuvers was recorded as primary outcome. Block performing features (ideal ultrasound-guided brachial plexus cords visualization, needle pathway planning time, needle tip and shaft visualization difficulty, requirement of extra needle maneuver due to insufficient local anesthetic distribution, block performance time, total procedure difficulty) and postoperative pain-related data (block intensities, pain scores and analgesic requirements) were all compared as secondary outcomes. RESULTS: The LC group patients required less ultrasound visualization time (median 14 s, range 11-23 s vs. median 42 s, range 15-67 s, p < 0.001) and fewer needle maneuvers (median 1, range 1-2 vs. median 3, range 2-4, p < 0.001) compared to the MC group. Similarly, the median block performance duration was shorter (median 67 s, range 47-94 s vs. median 140s, 90-204 s, p < 0.01) and procedures were perceived as easier (median 4, range 4-5 vs. median 3, range 2-5, p = 0.04) in the LC group. All other parameters were comparable (p > 0.05). CONCLUSION: The lateral approach required less needle maneuvers than the medial approach. Both techniques represented a good safety profile with favorable analgesic features.

Optimal analgesic regimen for total shoulder arthroplasty: a randomized controlled trial and network meta-analysis.

OBJECTIVE: Clinical approaches to analgesia following total shoulder arthroplasty include liposomal bupivacaine, local infiltration analgesia, single-shot interscalene block, and continuous interscalene block. However, the best method remains contentious. This study conducts a network meta-analysis comparing these four methods, aiming to identify the most effective analgesic approach. METHODS: Randomized controlled trials on analgesic regimens for total shoulder arthroplasty were identified through searches of PUBMED, Cochrane Central Register of Controlled Trials, EMBASE, Web of Science, and Scopus databases, covering their inception through November 2023. Network meta-analysis was performed using STATA 15.1, and the Cochrane Handbook version 5.1.0 risk of bias tool was employed for quality assessment of the literature. RESULTS: Twelve randomized controlled trials were included, comprising 1537 patients undergoing total shoulder arthroplasty. The interventions compared were ssISB, cISB, LIA, and LB. Regarding the quality of the literature, four studies were deemed low risk, one high risk, and seven moderate risk. The network meta-analysis revealed that in terms of VAS scores in the PACU, the ssISB group was the most effective, followed by cISB and LB, with LIA being the least effective. This pattern continued in VAS scores on the first and second postoperative days. Regarding morphine consumption, the cISB group showed the most significant reduction in the PACU and on the first postoperative day, while the LIA group performed best in total postoperative morphine consumption. The shortest average hospital stay was noted in the cISB group. CONCLUSION: The ssISB method excels in controlling early postoperative pain, particularly during the PACU stage and early postoperative period. Additionally, the cISB method is notable for reducing postoperative morphine consumption and shortening average hospital stays. While the LIA method ranks first in reducing total morphine consumption, it is weaker in pain control. The LB method is underwhelming across most assessment parameters. These findings underscore the importance of selecting appropriate analgesic strategies for different postoperative recovery phases and provide valuable insights for clinicians to optimize postoperative pain management. Furthermore, they suggest a need for future research to explore the specific application and effectiveness of these methods in varying clinical contexts.

Infraclavicular versus costoclavicular approaches to ultrasound-guided brachial plexus block: a systematic review and meta-analysis.

BACKGROUND: The costoclavicular approach to brachial plexus block may have a more favorable anatomy than the classic infraclavicular approach. However, there are conflicting results in the literature regarding the comparative effectiveness of these two techniques. METHODS: We systematically searched for Randomized Controlled Trials (RCTs) comparing costoclavicular with infraclavicular brachial plexus blocks for upper extremity surgeries on MEDLINE, EMBASE, and Ovid. The outcomes of interest were sensory and motor block onset times, performance times, block failure, and complication rate. We performed statistical analyses using RevMan 5.4 and assessed heterogeneity using the Cochran Q test and I2 statistics. We appraised the risk of bias according to Cochrane's Risk of Bias 2 tool. RESULTS: We included 5 RCTs and 374 patients, of whom 189 (50.5%) were randomized to undergo costoclavicular block. We found no statistically significant differences between the two techniques regarding sensory block onset time in minutes (Mean Difference [MD = -0.39 min]; 95% CI -2.46 to 1.68 min; p = 0.71); motor block onset time in minutes (MD = -0.34 min; 95% CI -0.90 to 0.22 min; p = 0.23); performance time in minutes (MD = -0.12 min; 95% CI -0.89 to 0.64 min; p = 0.75); incidence of block failure (RR = 1.59; 95% CI 0.63 to 3.39; p = 0.63); and incidence of complications (RR = 0.60; 95% CI 0.20 to 1.84; p = 0.37). CONCLUSION: This meta-analysis suggests that the CCV block may exhibit similar sensory and motor onset times when compared to the classic ICV approach in adults undergoing distal upper extremity surgery, with comparable rates of block failure and complications.

Just the facts: brachial plexus blocks for upper extremity injuries in the emergency department.

Ultrasound-guided nerve blocks (UGNBs) are becoming a more common method for pain control in the emergency department. Specifically, brachial plexus blocks have shown promise for acute upper extremity injuries as well as an alternative to procedural sedation for glenohumeral reductions. Unfortunately, there is minimal discussion in the EM literature regarding phrenic nerve paralysis (a well-known complication from brachial plexus blocks). The anatomy of the brachial plexus, its relationship to the phrenic nerve, and why ultrasound-guided brachial plexus blocks can cause phrenic nerve paralysis and resultant respiratory impairment will be discussed. The focus on patient safety is paramount, and those with preexisting respiratory conditions, extremes of age or weight, spinal deformities, previous neck injuries, and anatomical variations are at greater risk. We put forth different block strategies for risk mitigation, including patient selection, volume and type of anesthetic, block location, postprocedural monitoring, and specific discharge instructions. Understanding the benefits and risks of UGNBs is critical for emergency physicians to provide effective pain control while ensuring optimal patient safety.

Application and Research Progress of Ultrasound-Guided Brachial Plexus Block Through Costoclavicular Space Approach in Upper Limb Surgery.

Objective: Exploring newer approaches to brachial plexus block is crucial for improving surgical outcomes and patient comfort. This study aims to review the application and research progress of ultrasound-guided brachial plexus block via the costoclavicular space approach in upper limb surgery. Methods: This study provides a comprehensive review of existing literature, studies, and clinical cases related to the costoclavicular approach. The advantages and disadvantages of conventional approaches for brachial plexus block, including the intermuscular groove method, supraclavicular method, and axillary approach, are discussed. The anatomical characteristics of the costoclavicular space are examined, and the methods of brachial plexus nerve block using ultrasound-guided costoclavicular space approach are described. It holds great promise for enhancing patient care and increasing the overall success rate of surgical procedures. Results: The costoclavicular space approach for brachial plexus block offers several advantages, including stable anatomical structure, low nerve variation rate, and clear visualization of each nerve bundle under ultrasound imaging. Compared to traditional approaches, ultrasound-guided brachial plexus block via the costoclavicular space approach has a high success rate, rapid onset of anesthesia, and high safety. Conclusion: Ultrasound-guided brachial plexus block via the costoclavicular space approach is effective and safe in upper limb surgery. It provides good anesthesia and postoperative analgesia, making it a valuable technique for various upper limb surgeries. The potential clinical significance of our findings lies in the possibility that ultrasound-guided costoclavicular space approach, with its enhanced precision and patient outcomes, could play a pivotal role in improving upper limb surgical procedures.

Fascial plane approach to anesthetizing the radial, median, and ulnar nerves: an educational review.

Brachial plexus block provides effective anesthesia and analgesia for upper extremity surgery but requires injection of large anesthetic volumes near major vascular structures. Moreover, the extensive motor and sensory loss produced by plexus block often exceeds the neural distribution needed for corresponding surgical procedures.High-resolution ultrasound facilitates selective nerve blocks at nearly every level of the upper extremity. We present fascial plane injection techniques for selective radial, median, and ulnar nerve blocks. These techniques can be used to match sensory distribution with specific surgical procedures. They are performed using low anesthetic volumes and without proximity to nerves or vascular structures. In this article, fresh cadaver dissections with corresponding ultrasound images are used to demonstrate stepwise fascial plane techniques for the radial, median, and ulnar nerves. These techniques are performed using familiar anatomic landmarks.Practical applications of these techniques are demonstrated for commonly performed procedures of the upper extremity. Corresponding injection volumes with duration of postoperative analgesia are presented. Selected injections are described for both surgical anesthesia and postoperative analgesia.Selective fascial plane injections can provide surgical anesthesia and postoperative analgesia in settings that might otherwise require much larger volumes of local anesthetic. These selective nerve blocks can match sensory loss with the anatomic pain distribution in each patient. Reliable techniques for selective nerve blocks of the upper extremity can expand the capabilities for ultrasound-guided regional anesthesia.

Comparison of shoulder anterior capsular block and interscalene brachial plexus block for shoulder arthroscopy: a preliminary analysis.

BACKGROUND: This study aims to reveal the perioperative analgesic efficacy of a new technique, anterior capsular shoulder block, in treating pain after shoulder arthroscopy compared to the interscalene brachial plexus block. METHODS: The study design is randomized, prospective, interventional, standardized and double-blind in the setting of orthopedic operating room and orthopedic postoperative ward. Forty patients between 18-90 years of age and with American Society of Anesthesiologists Physical Status classification I to III who received arthroscopic cuff repair surgery were randomized into two (1:1 distribution; N.=20) groups. The interventions were interscalene brachial plexus block for Group A and shoulder anterior capsular block for Group B. Primary measurements were pain scores within 48 hours. Secondarily total analgesia requirement, intraoperative heart rate and blood pressure, arthroscopic image quality were evaluated. RESULTS: Pain scores within postoperative 48 hours were similar between SHAC and ISB groups with no significant difference (P>0.05). Total analgesia requirement, intraoperative and postoperative rescue analgesia, was also similar with no significance (P>0.05). CONCLUSIONS: This study demonstrated that the anterior capsular shoulder block is an effective alternative with similar results to the interscalene brachial plexus block for managing pain after shoulder arthroscopy.

Rebound pain after interscalene brachial plexus block for shoulder surgery: a randomized clinical trial of the effect of different multimodal analgesia regimens.

BACKGROUND: Rebound pain is characterized by sudden, significant acute postoperative pain occurring after the resolution of inter-scalene block (ISB); it affects the quality of recovery postoperatively. Dexamethasone increases ISB resolution time and decreases opioid consumption and the incidence of rebound pain. OBJECTIVE: Evaluate whether multimodal analgesia including intravenous dexamethasone administration with preoperative ISB reduces the incidence of rebound pain. DESIGN: Prospective, randomized, controlled trial. SETTING: Tertiary university hospital. SAMPLE SIZE: 60 patients. PATIENTS AND METHODS: Patients who underwent shoulder surgery under general anesthesia were assigned randomly to two different multimodal analgesia protocols. Thirty patients received 5 mg IV dexamethasone with non-steroid, paracetamol, and ISB with 15 mL 0.5% bupivacaine, while the control patients received the same regimen and ISB with 15 mL 0.5% bupivacaine without dexamethasone. Postoperative opioids were given to any patient on demand. MAIN OUTCOMES MEASURES: Effect of IV dexamethasone on pain score and incidence of rebound pain after ISB resolution and postoperative opioid consumption at 0-48 hours, numerical pain rating scale (NPRS) scores, sleep scale scores, and quality of recovery-15 scores (QoR-15). RESULTS: The incidence of rebound pain was lower in the dexamethasone group than in the control group (73.3% and 30%, respectively, P=.001). NPRS scores after ISB resolution were lower in the dexamethasone group (5 ([4-7]), 8 ([5.75-8]), P<.001, respectively). Those who received IV dexamethasone had less sleep disturbances (P<.001) and higher QoR-15 on day 1 (P<.001) and day 7 (P=.020) postoperatively. CONCLUSIONS: IV dexamethasone added to the ISB block resulted in a lower incidence of rebound pain. In addition, better results were obtained in postoperative sleep quality and QoR-15. LIMITATIONS: Single-center study.

Combined Infraclavicular-Suprascapular Nerve Blocks Compared With Interscalene Block for Arthroscopic Rotator Cuff Repair: A Prospective, Randomized, Double-blind, and Comparative Clinical Trial.

BACKGROUND: The gold standard postoperative analgesia protocol for arthroscopic rotator cuff repair procedures is the interscalene block (ISB), which prevents the significant consequences of phrenic nerve block associated with hemidiaphragmatic paralysis (HDP). The infraclavicular brachial plexus block (BPB) combined with the suprascapular nerve block (SSNB) had the same analgesic efficacy as the infraclavicular BPB alone, with no effect on respiration. OBJECTIVES: Therefore, the study aimed to assess the HDP and analgesic efficacy of both approaches in controlling pain following arthroscopic rotator cuff repair surgeries. STUDY DESIGN: A prospective, randomized, double-blind, and comparative clinical trial. SETTING: The study comprised 66 patients. They were separated into 2 equal parallel groups 33 patients each: the ISB group and the costoclavicular and suprascapular block (CSB) group. METHODS: The ISB group obtained the ISB followed by the general anesthesia. The CSB group received infraclavicular blockade using the costoclavicular approach and SSNB followed by general anesthesia. RESULTS: Considering morphine utilization during the first day following the operation, the groups demonstrated an insignificant difference. The CSB group showed a decreased rate of diaphragmatic paralysis. LIMITATIONS: There was no control group. And, the blocks might take a long time to be performed up to 30 minutes. Also, there were no validated criteria to define HDP based on M-mode ultrasound measurements. CONCLUSIONS: The employment of the costoclavicular block in combination with the suprascapular block may provide a comparable analgesic potency to the sole use of the standard ISB with no HDP.

Single injection technique with ultrasound-guided superficial cervical fascia block combined with brachial plexus block in clavicular surgery: a prospective randomized comparative trial.

BACKGROUND: To investigate the effects of a single injection technique with ultrasound-guided superficial cervical fascia block combined with brachial plexus block in clavicular surgery. METHODS: Forty patients, 25 males and 15 females, aged 18-85 years with ASA class I or II underwent unilateral clavicular fracture internal fixation. The patients were randomly divided into a superficial cervical plexus block group (group S, n = 20) and a superficial cervical fascia block group (group F, n = 20). First, the brachial plexus of the intermuscular sulcus of all patients was blocked with an ultrasound-guided injection of one injection with 15ml 0.33% ropivacaine 15ml in both groups. Second, the superficial cervical plexus was blocked by another injection of 5-8ml 0.33% ropivacaine in group S, and the superficial cervical fascia was blocked by an injection with 5-8ml 0.33% ropivacaine in Group F. We evaluated operation time, onset time of anaesthesia, effective time and the grades of nerve block effect in the two groups. Additionally, we evaluated the incidences of local anaesthetic poisoning, hoarseness, dyspnoea, and postoperative nausea and vomiting, and the number of patients requiring remedial analgesia within 24 h. Repeated measurements were analysed by repeated data analysis of variance, and count data were compared by the χ2 test. A P value < 0.05 was considered statistically significant. RESULTS: The operation time and onset time in Group F were significantly shorter than those in group S (P < 0.05); the effect of intraoperative block was better than that in group S (P < 0.05), and the effective time was significantly longer in group F than in group S (P < 0.05). However, no severe case of dyspnoea, local anaesthetic poisoning or hoarseness after anaesthesia occurred in either of two groups. There was no significant difference in the rate of postoperative salvage analgesia or that of postoperative nausea and vomiting between the two groups. CONCLUSIONS: The application of the single injection technique with ultrasound-guided superficial cervical fascia block combined with brachial plexus block in clavicular surgery is beneficial because it shortens the operation time, has a faster onset, produces a more effective block and prolongs the longer analgesia time. TRIAL REGISTRATION: Chinese Clinical Trial Registry- ChiCTR2200064642(13/10/2022).

Ultrasound-guided Retroclavicular Approach Versus Costoclavicular Approach of Infraclavicular Brachial Plexus Block for Upper Limb Surgeries.

BACKGROUND: Regional anesthesia for an upper limb provides many advantages over general anesthesia, especially in orthopedic surgery. OBJECTIVES: This trial aimed to compare a retroclavicular approach to the infraclavicular brachial plexus with a costoclavicular approach in term of needle time, image time, and procedure time, and comparing both with the classic technique for upper limb surgeries guided by ultrasound. STUDY DESIGN: Prospective, randomized, single-blinded controlled trial. SETTING: Minia University, Faculty of Medicine, Anesthesia and Intensive Care Department. METHODS: Sixty patients of both sees with an American Society of Anesthesiologists  Classification of I and II, a BMI (kg/m2) of 20-35, aged from 18-60 years who were scheduled for a forearm or hand surgery under infraclavicular brachial plexus block were divided into 3 parallel equal groups. Group I (RC) received a retroclavicular approach.  Group II (CC)received a costoclavicular approach.  Group III (CT) received the classic technique. Procedure time, the sum of the imaging and needling times, was our primary outcome. Secondary outcomes were the motor and sensory block success rate 30 minutes postinjection of local anesthesia, duration of motor and sensory block, Visual Analog Score, first analgesic need, total analgesia requirements during the first postoperative 24 hours, and any complications. RESULTS: The procedure and needle times were significantly decreased in the retroclavicular group due to better needle visibility. There was no significant difference regarding sensory and motor block data. The VAS score in the first postoperative 24 hours showed no statistical significance. Regarding analgesic data and patient satisfaction, there was no statistical significance among the 3 studied groups. There were no complications in any of the used approaches. LIMITATION: Our trial did not include patients with a BMI > 35. CONCLUSIONS: The retroclavicular approach is superior because of its decreased procedure time and needle time than both the costoclavicular approach and classic approach.

The 90% minimum effective volume of 0.5 ropivacaine for ultrasound-guided supraclavicular brachial plexus block : A biased coin up-and-down design.

BACKGROUND: Ultrasound-guided supraclavicular brachial plexus block is widely used in upper limb surgery; however, it requires a higher dose (20-30 mL) of local anesthetic. In this study, we aimed to determine the 90% minimum effective volume for ultrasound-guided supraclavicular brachial plexus block. METHODS: All patients received an ultrasound-guided two-point injection of 0.5% ropivacaine at a starting volume of 0.18 mL/mm2 cross-sectional nerve area. In cases of a successful block, the next patient had the same volume with a probability of 0.89, and the volume was reduced by 0.04 mL/mm2 cross-sectional nerve area with a probability of 0.11. When the block failed, the dose was increased by 0.04 mL/mm2 cross-sectional nerve area. After 45 cases of successful blocks, the 90% minimum effective volume of local anesthetic was calculated using the centered isotonic regression function. RESULTS: Centered isotonic regression analysis resulted in a 90% minimum effective volume and a 95% confidence interval of 0.189 mL/mm2 and 0.176-0.225 mL/mm2 for the supraclavicular brachial plexus block. CONCLUSION: A good blocking effect can be achieved with 0.189 mL/mm2 of 0.5% ropivacaine with more precise dosing, thereby reducing the risk of local anesthetic poisoning.

Retrospective evaluation of the effects of traditional interscalene block alone versus combined with superior truncus block-associated diaphragm paralysis during arthroscopic shoulder surgery.

OBJECTIVES: The aim of this study was to investigate the effects of traditional interscalene block (ISB) alone and ISB combined with superior truncus block (STB)-associated diaphragm paralysis evaluated by ultrasound, duration of analgesia, and rate of complication in patients undergoing arthroscopic shoulder surgery. PATIENTS AND METHODS: Between January 2020 and December 2022, a total of 285 patients (158 males, 127 females; mean age: 48.0±15.1 years; range, 18 to 80 years) who underwent arthroscopic shoulder surgery under ISB, either alone or combined with STB, were retrospectively analyzed. The patients were operated under ISB alone using 30 mL 0.5% bupivacaine (n=140) or ISB using 10 mL (n=67) or 5 mL 0.5% bupivacaine (n=78) combined with STB using 20 mL 0.5% bupivacaine. Ultrasound reports of all patients' diaphragm function were also retrieved. Duration of analgesia, need for additional analgesics, and the type of analgesic drugs, and evaluations of patient and surgeon satisfactions were evaluated. Degree of diaphragm paralysis considered as complete (≥75%), partial (25.1 to 74.9%) and no paralysis (≤25%) were evaluated for comparison between the block types. RESULTS: The patients underwent operation due to rotator cuff rupture (n=218) or Bankart (n=67). Duration of analgesia, need for additional analgesia, and the type of analgesic drugs used were comparable between the block types. The most common complication was Horner syndrome (n=96, 33.68%) which was significantly lower in ISB (5 mL) +STB (20 mL) than the others (17.9% vs. 41.4% and 37.3%, p=0.002). The ISB (5 mL bupivacaine 0.5%) + STB (20 mL bupivacaine 0.5%) resulted in less complete diaphragm paralysis with adequate surgical anesthesia not requiring general anesthesia. CONCLUSION: The ISB using 5 mL of 0.5% bupivacaine + STB instead of traditional ISB alone can be preferred due to the low rate of complete hemi-diaphragm paralysis with adequate surgical anesthesia/analgesia and high patient and surgeon satisfaction.